What is the Two-Midnight rule in Medicare?
Whether or not to admit you as an inpatient to a hospital is a decision made by your doctor after reviewing your medical situation, and they decide whether it is necessary to admit you to the hospital. According to Medicare, an inpatient admission is generally appropriate when you’re expected to need 2 or more midnights […]
How is it possible for Medicare Advantage plans to cost the consumer zero?
There are two parts to how Medicare Advantage plans get paid. The first is the premium members pay; how the premium depends on the benefits of the plan you purchase. It can be as low as $0, or it can be higher in other cases. Secondly, since Medicare Advantage Plans completely replace Original Medicare, Medicare […]
Changes to Medicare Part D prescription drugs in 2026
In 2026, Medicare Part D continues its significant modifications aimed at enhancing affordability and accessibility for beneficiaries. The cornerstone remains the $2,000 yearly limit on out-of-pocket expenses for prescription drugs, which was implemented in 2025. This cap still offers significant financial relief to those who faced higher costs. The elimination of the 5% coinsurance requirement […]
Can I use my Medicare coverage to utilize telehealth services?
If you have original Medicare, Part B will cover telehealth services, and you will have to pay a 20% coinsurance of the Medicare-approved amount for your doctor or other health care provider’s services after you pay the Part B deductible. You will have to pay the same amount for most telehealth services as if you […]
What does “step therapy” mean in Medicare drug coverage?
Each Medicare Part D plan has a list of covered drugs that are called a formulary. Within every formulary, there are a set of rules applied to the prescription drugs covered by the plan. One of those rules is called step-therapy. If you get a prescription for a medication that has step-therapy rules, there is […]
When does “catastrophic coverage” kick in with Medicare Part D coverage?
Starting in 2025, the structure of Medicare Part D changed significantly, and in 2026, catastrophic coverage continues to begin once your out-of-pocket spending on covered prescription drugs reaches $2,000 for the year. This includes what you pay directly and certain payments made on your behalf, such as through the Extra Help program. Once you reach […]
If I enroll in a Medicare plan with an initial deductible, does the deductible determine when I go into the “Doughnut hole”?
In 2026, Medicare Part D continues to offer simplified prescription drug coverage. The coverage gap, commonly known as the “donut hole,” remains eliminated. Now, after meeting your plan’s deductible (which can be up to $605 in 2026), you enter the initial coverage phase, where you pay a portion of your prescription costs. Once your out-of-pocket […]
What is the “Doughnut hole” in Part D Medicare coverage, and how does it work?
The donut hole no longer exists in Medicare Part D as of 2025. Previously, beneficiaries would enter a coverage gap after reaching a certain spending limit on prescriptions. In that phase, they paid a larger share of drug costs until reaching catastrophic coverage. Starting in 2025, a new out-of-pocket cap replaced the old donut hole […]
What if I need a drug that isn’t on the Medicare Formulary or costs too much?
If your physician determines that you need a drug that is not on a Part D plans formulary, they can ask the insurance company for an exception. However, there are rarely drugs that are not on the formulary that an insurance plan will grant an exception for. In most cases, these are experimental drugs that […]
What is a “formulary” in Part D Medicare?
Every Part D plan has a list of covered drugs called a formulary. Medicare provides insurance companies that sell Part D plans guidelines for the classes of drugs they have to cover but does not always specify the exact drugs that must be included on the formulary. Medicare excludes some drugs from their list of […]